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and Consumer Services (Information Technology Services)

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County name ________________________
Return Request to:
Administrative Officer
NCDA&CS
1614 Mail Service Center
Raleigh, N.C. 27699-1614
Phone: 919.715.6105
North Carolina Department of Agriculture
and Consumer Services
Steve Troxler, Commissioner
Catherine Stogner,
Director
Budget & Finance
www.ncagr.gov/swc
1614 Mail Service Center, Raleigh, N.C. 27699-1614 919.715.6105
An Equal Opportunity Affirmative Action Employer
For your convenience and benefit, the State of North Carolina offers supervisor travel reimbursement
electronically, rather than by check. Your payments will be deposited into the checking or savings account of your
choice. In addition to having the money deposited electronically, you may also be notified of the deposit
electronically, either by fax or by e-mail. The fax or e-mail will provide you with all the information that would
normally be on your check stub.
ELECTRONIC PAYMENT REQUEST FORM
• ATTACH A VOID CHECK, PRINT THE INFORMATION BELOW and MAIL to DSWC Administrative
Officer at the address above.
Payee Name
Federal ID # / Social Security # ________________________________________________________
Bank Name
Bank routing number
( ) Checking account #
( ) Savings account #
________________________________________________________
________________________________________________________
• FAX number or e-mail address for payment notification. Place a check mark in front of the method of notification
you prefer.
( ) FAX # ( __ __ __ ) __ __ __ - __ __ __ __ OR
( ) E-mail address
________________________________________________________
Authorized Signature: ________________________________________ Date:_________
Title: ________________________________________________________
( ) Phone # ( __ __ __ ) __ __ __ - __ __ __
(ATTACH A VOID CHECK)
(ATTACH A VOID CHECK)
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Completed 14 August 2020

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